Neurosurgery最新文献

Background and objectives: The utility of dynamic MRI (dMRI) in surgical planning and outcomes for degenerative cervical myelopathy (DCM) has not been validated in any prospective randomized trials.

Methods: In this hospital-based randomized controlled trial conducted between February 2023 and December 2024, patients with DCM were randomized into 2 groups: the Static MRI Group, where surgery was guided by conventional static MRI alone, and the dMRI Group, in which dMRI was performed, with the potential to alter the surgical approach. The primary outcome was recovery rate (RR) at 3 months. Secondary outcomes included postoperative changes in modified Japanese Orthopaedic Association scores and Nurick grades, surgical plan alterations, comparison of surgical approaches, and complication rates.

Results: Seventy-four patients were analyzed at a 3-month follow-up. The dMRI group had a significantly higher mean RR (55.42% ± 29.05%) than the Static group (46.76% ± 29.51%) (P = .044). A RR of ≥50% was observed in 91.9% of patients in the dMRI group, compared with 59.4% in the static MRI group (P = .002). Modified Japanese Orthopaedic Association scores improved more in the dMRI group (15.47 ± 2.62 vs 13.77 ± 2.66, P = .007). While Nurick grades improved in both groups, the intergroup difference was not statistically significant (P = .151). dMRI altered the surgical plan in 59.5% of cases. Anterior approaches yielded better RR but had more complications. By contrast, posterior approaches had fewer but more severe complications including mortality.

Conclusion: dMRI enhances the detection of clinically significant cord compression and may aid in surgical decision-making, potentially contributing to superior functional outcomes in DCM. Further studies are required to determine its impact on long-term functional outcomes.

Background and objectives: Prognosis of melanoma with leptomeningeal disease (LMD) is poor (median overall survival of 5.1 months). Intrathecal (IT) nivolumab appears safe, although its efficacy remains uncertain. We investigated the feasibility, safety, and efficacy of continuous IT nivolumab.

Methods: This was a retrospective analysis of 11 melanoma patients with progressive LMD (MelBase; NCT02828202) treated as part of the patients' care with continuous IT nivolumab administered through spinal (n = 10) or ventricular catheter (n = 1).

Results: Patients (5 women, median age 52) with Eastern Cooperative Oncology Group ≤1 (except for 1) and stable extracranial disease (except for 4) were treated over a median duration of 1.5 months and followed for 2.5 months. Seven presented symptomatic LMD. Primary tumors were mostly cutaneous (n = 8) and BRAF-mutated (n = 10). All patients had progressed on systemic immunotherapy; 7 had received brain radiotherapy (whole brain radiotherapy [n = 3]; stereotactic radiosurgery [n = 4]). Concomitant therapies included corticosteroids >10 mg (n = 5), intravenous nivolumab (first 3 months of IT therapy, n = 1), and targeted therapies (n = 7). The median overall survival was 2.5 months, with 3 patients surviving for more than a year. Reversible treatment-related adverse events occurred in 5 patients: meningoencephalitis (grade 3, n = 1), intracranial hemorrhage (grade 1, n = 1), intracranial hypotension (grade 2, n = 2; grade 1, n = 1). Baseline levels of nivolumab in the cerebrospinal fluid (CSF) were <2 µg/mL, even among patients with plasma detection. CSF concentrations of nivolumab at steady state varied from 36 to 97 µg/mL, with clearances of 4.3-15.7 mL/h. Next-generation sequencing identified CSF genomic profiles correlating with clinical progression in 4 patients.

Conclusion: These findings warrant further trials on IT nivolumab.

Background and objectives: Surgical decompression is commonly required to relieve symptoms of cervical radiculopathy and allow for functional recovery. There are only a handful of studies analyzing return-to-work (RTW) outcomes after cervical spine surgery for cervical radiculopathy. This study seeks to elucidate RTW outcomes and to identify predictors preventing RTW in patients surgically treated for cervical radiculopathy in a Swedish nationwide prospective registry.

Methods: A nationwide cohort analysis was conducted using prospectively gathered data from the Swedish Spine Registry. All patients with documented postoperative outcomes focusing on 1-year RTW rates were included. To identify predictive factors influencing RTW at 1 year postoperatively, separate univariable and multivariable logistic regression models were developed, incorporating demographic, functional and clinical, as well as preoperative and postoperative data, and occupational characteristics.

Results: A total of 3929 patients were included with an average age of 49.5 years, with most patients working in moderate- or high-intensity jobs and nearly half on sick leave before surgery. Most surgeries were elective, and an anterior approach was preferred. At the 1-year mark after surgery, 85% of patients had returned to work, with full-time RTW reaching 67% and part-time RTW 18%. In this cohort, 15% had not returned to work at all. Higher age, previous cervical spine surgery, high job intensity, preoperative full-time sick leave and full-time sickness benefits, longer preoperative arm pain durations as well as higher preoperative Neck Disability Index, and lower EuroQOL 5 dimensions scores were independently associated with a reduced likelihood of RTW at 1 year postoperatively.

Conclusion: Eighty-five percent of the patients surgically treated for radiculopathy RTW within 1 year. Higher age, jobs with greater physical demands, longer duration of arm pain, higher preoperative neck disability index and lower EuroQOL 5 dimensions scores, as well as being on full-time sick leave, were all linked to a reduced chance of RTW.

Background and objectives: The rapid expansion of oncologic systemic therapy has produced major advances for patients with cancer. This array of pharmacologic mechanisms also presents challenges for neurosurgeons. Many agents impair wound healing, hemostasis, and immune function, elevating perioperative risk. Yet, consolidated evidence-based guidance for neurosurgical drug management remains limited. Our goal is to provide a comprehensive, clinically actionable framework for perioperative management of targeted and biologic therapies in patients undergoing neurosurgical procedures.

Methods: We conducted a systematic review of pivotal clinical trials, US Food and Drug Administration safety data, meta-analyses, and society guidelines to assess the impact of key agents on surgical outcomes. Drug classes were evaluated based on pharmacokinetics, mechanism of action, and adverse events relevant to wound healing, bleeding, and immune dysregulation. Recommendations were stratified by risk level and supported by available evidence and expert consensus.

Results: Wound healing risk was highest with anti-vascular endothelial growth factor (VEGF) monoclonal antibodies and mammalian target of rapamycin inhibitors, warranting extended preoperative holds (≥4 weeks for VEGF inhibitors, ≥1 week for mammalian target of rapamycin agents) and postoperative delays of 2 to 4 weeks (fibroblast and angiogenesis suppression). Bleeding risk was most significant with VEGF receptor-tyrosine kinase inhibitors and Bruton's tyrosine kinase inhibitors (eg, ibrutinib), independent of platelet count, necessitating short-term holds of up to 1 week with resumption after 3 to 7 days. Immunosuppression noted with CDK4/6 inhibitors, janus kinase inhibitors, and biologic immunomodulators (eg, TNF, IL-6, CD20 blockers), increasing postoperative infection risk. These agents often require brief interruption (2-7 days) with resumption 1 to 2 weeks postoperative depending on half-life and schedule. For BRAF/MEK inhibitors and immune checkpoint inhibitors, perioperative data are limited.

Conclusion: Modern systemic therapies necessitate refinement of perioperative management in neurosurgical oncology. This review synthesizes data into a pragmatic framework for drug timing and risk mitigation. Considering interruption intervals is essential to balance surgical safety with oncologic control. Integrating these principles can reduce complications, standardize care, and improve outcomes for this complex patient population.

Background and objectives: Despite advances in treatment for intracranial aneurysms, recurrence remains a clinical challenge. Studies have suggested associations between treatment modality, aneurysm morphology, and recanalization risk, but comprehensive evaluation of these factors and their relationships is limited. The goal of this study was to evaluate the role of aneurysm location and packing density (PD) as predictors for recurrence.

Methods: This is a retrospective cohort study where records of patients who underwent coiling for intracranial aneurysms from 2013 to 2023 from a single institution were reviewed. Recurrence was defined as worsening of angiographic aneurysm occlusion status. Demographics, aneurysm characteristics, clinical outcomes, and follow-up data were recorded. Analysis was performed in RStudio.

Results: A total of 505 were included; 195 aneurysms were ruptured (38.6%). The most frequent locations were anterior communicating artery (163), internal carotid artery (85), basilar (76), posterior communicating artery (63), and middle cerebral artery (43). Mean PD was 23.3%, with 109 recurrences (21.6%) and 76 retreatments (15.1%); 31 patients (6.1%) experienced thromboembolic complications. In multivariable analysis, incomplete occlusion (Raymond-Roy [RR] Grades II-III), presence of an incorporated branch vessel, and higher size ratio independently predicted recurrence, whereas male sex and age older than 75 years were protective. Size ratio also predicted retreatment, while stent-assisted coiling reduced the likelihood of retreatment. Although higher PD was associated with better immediate RR Grade, PD (including extremes <15% vs >30%), aneurysm volume, and anatomical location were not independently associated with recurrence or retreatment after adjustment.

Conclusion: In this modern series, the immediate RR Grade, not PD or anatomical site, drove long-term durability; PD improved the index occlusion but had no independent association with recurrence after adjustment. Incorporated perforators independently increased recurrence risk, and stent assistance reduced retreatment. These data reframe technical priorities toward achieving complete occlusion safely, especially in perforator-bearing lesions, rather than chasing PD thresholds alone in the contemporary era.

Background and objectives: Meningiomas invading the superior sagittal sinus (SSS) present significant challenges for surgical management. Stereotactic radiosurgery (SRS) is increasingly used as a primary or salvage management in these difficult cases. The aims of this study were to evaluate the rate of long-term tumor control and the long-term neurological outcomes.

Methods: The authors retrospectively reviewed outcomes in 248 patients (152 females, 67.3%; median age, 61 years) with SSS invasive meningiomas who underwent primary or salvage SRS during a 22-year interval. The clinical presentation, radiographic characteristics, and neurological function of each patient were recorded. A total of 140 patients underwent resection before SRS for their SSS meningiomas. Overall, 56% of the patient had tumors involve the posterior one-third of the SSS; 51.6% of patients presented with peritumoral edema before SRS.

Results: The 1-, 2-, 5-, and 10-year local tumor control (LTC) rates were 97.7%, 94.1%, 85.7%, and 78.3%, respectively. Upfront SRS for SSS-invading meningiomas provided LTC comparable with that observed with salvage SRS for histologically confirmed WHO Grade I meningiomas (hazard ratio 0.86, CI 95% 0.33-2.24, P = .76). Tumor volumes <5.2 cc predicted better LTC (hazard ratio 5.1, CI 95% 1.9-19.3, P = .03). The median overall survival after SRS was 14.6 years. Ten patients (4%) died related to documented local intracranial tumor progression. A total of 12 patients (4.8%) developed symptomatic adverse radiation effects at median duration post-SRS of 14 months (range 2-182 months). Motor function improved in 20% patients who presented with motor weakness, after SRS.

Conclusion: SRS is safe and effective in managing small to medium sized SSS invading meningiomas, especially when the tumors involve the posterior one-third of the SSS. For larger SSS meningioma with symptomatic mass effect, adjuvant SRS for residual or recurrent tumors provides long-term tumor control.

Background and objectives: Free and open access to research data and findings promotes equity in access to healthcare knowledge and equity in patient care and treatment. To benefit the health care of the population studied, research findings must be accessible to clinicians, academics, and policymakers serving those populations. The aim of this study was to assess the extent of published Tanzanian neurosurgical data and its accessibility to those practicing within the country.

Methods: A systematic review of all published neurosurgical studies from Tanzania was conducted. Authorship, funding, and open-access status were recorded. Tanzanian neurosurgeons were surveyed by telephone or in person about their methods of accessing literature.

Results: We identified 96 Tanzanian neurosurgical studies published in 42 journals between 1982 and 2023 with an exponentially increasing number of publications per year. Fifty-nine studies (62%) are available open access at the publisher. Open access publication is associated with Tanzanian first authorship (odds ratio = 2.6, 95% CI: 1.0-6.8) or last authorship (odds ratio = 2.7, 95% CI: 1.0-7.1). However, overall only 34 of 96 studies (35%) had Tanzanian first authors and 32 of 96 (33%) had Tanzanian last authors. We contacted 26 of 27 neurosurgeons working in Tanzania. None had in-country institutional library service access. One used a research initiative login to access neurosurgical literature, and 2 used institutional logins from outside Tanzania. Ten neurosurgeons (38%) reported alternative methods of accessing literature behind a paywall such as Sci-Hub or direct contact with authors. These methods could have given access to all but 9 of 96 neurosurgical studies (9%).

Conclusion: Only 62% of Tanzanian neurosurgical literature is easily freely accessible to Tanzanian neurosurgeons, and 9% of all Tanzanian neurosurgical literature is extremely challenging to access for neurosurgeons working in Tanzania. Expanding open-access publishing, repositories, and publisher and institutional initiatives for equitable data and publication access are crucial for improving access to local data to improve patient care.

The blood-brain barrier (BBB) presents a major challenge in administering pharmacological therapy for neurological disorders such as chronic pain. Focused ultrasound (FUS)-mediated BBB opening (BBBO) presents an alternative means of drug delivery. We examine potential candidate drugs and particle technology for use in FUS-mediated BBBO for treatment of pain. In this scoping review, we searched Pubmed and Embase databases for articles discussing FUS and pain. Using the Rayyan platform, we identified 705 articles and 376 were identified for abstract review, ultimately resulting in text review of 95. This scoping review was designed to address the following: (1) What are the limitations of chronic pain treatments in BBB penetration? and (2) What advancements in particles are likely to be used in FUS and BBBO for chronic pain? Despite interest in FUS-mediated BBBO for drug delivery in central nervous system disorders, no human studies have been conducted to assess its efficacy for the treatment of chronic pain. Preclinical work shows that many receptor agonists/antagonists reduce allodynia and hyperalgesia when administered directly to the brain, but not peripherally. Recent advances in particle and FUS technology allows precise targeting of specific brain regions and may hinder efflux and degradation of compounds at target. In combination with advancements in particle and FUS technology, drugs for treatment of chronic pain have been successful in preclinical models. Care must be chosen for selecting parameters, drugs, and particles for initial clinical studies to move the field forward successfully.

Background and objectives: This study aimed to investigate the clinical presentation, natural history, and long-term outcome of sporadic cerebral cavernous malformations (CCMs) based on initial Zabramski classification.

Methods: A prospective cohort of 285 patients with sporadic CCMs was analyzed. Patients were classified into Zabramski Types I-IV based on diagnostic MRI. Clinical presentation, lesion size, location, and developmental venous anomaly presence were recorded. Prospective symptomatic hemorrhage (SH) (censored at first hemorrhage, surgery, or last follow-up) and functional outcomes were assessed using Kaplan-Meier and Cox regression analyses. Functional outcomes were measured with the modified Rankin Scale (mRS) at baseline, annually, and at the last follow-up.

Results: The cohort included 58.9% women and 41.1% men, with a mean age at diagnosis of 44.5 years. Zabramski Types I-IV (n = 113, 125, 40, and 7, respectively) differed significantly in clinical presentation ( P < .001). Type I lesions were symptomatic in 97.3%, Types II and III in 34.4% and 22.5%, respectively, while all Type IV lesions were asymptomatic. Type I lesions had the highest annual hemorrhage rate (13.9% per year) and a 5-year cumulative risk of 50.6%. Types II and III had lower rates (2.9% and 1.8%), whereas no hemorrhages occurred in Type IV lesions. At baseline, 70.8% of Type I patients had mRS ≥2, which decreased to 35.4% at the last follow-up. Type III lesions had favorable outcomes, with 7.5% of patients having mRS ≥2 at the last follow-up. Type IV lesions remained asymptomatic throughout. Severe SH significantly increased the odds of poor outcomes (mRS ≥3; P < .001), whereas Zabramski type was not predictive of outcomes after adjustment.

Conclusion: Zabramski classification aids in stratifying hemorrhage risk and guiding management in CCMs. Severe SH is a critical determinant of functional outcomes, underscoring the need for comprehensive risk assessments and individualized patient care strategies.

Background and objectives: It is unknown what determines the volume of aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate the features associated to the burden of subarachnoid hemorrhage after aneurysm rupture and its impact on clinical outcomes.

Methods: Patients admitted with aSAH between 2009 and 2022 were included. Clinical data were obtained from electronic medical records. Aneurysm location and morphological measurements were assessed using digital subtraction angiography. aSAH volume was objectively quantified on admission noncontrast computed tomography using semiautomated software. Univariate and multivariate analyses were performed to identify predictors of hemorrhage volume and examine its association with delayed cerebral ischemia (DCI), clinical vasospasm, and 7-day mortality in younger (18-64 years) and elderly (≥65 years) patients.

Results: Two hundred ruptured intracranial aneurysms were analyzed. Ruptured bifurcating aneurysms exhibited larger hemorrhage volume compared with sidewall aneurysms (23.16 mL, IQR: 34.2 vs 11.95 mL, IQR: 20.9, P = .002). In multivariate analysis, age (exp β 1.02; 95% CI 1.01-1.03; P < .001), Hunt and Hess (exp β 1.46, 95% CI: 1.31-1.62, P <.001), and bifurcation aneurysms (exp β 1.76; 95% CI 1.37-2.26; P <.001) were correlated with increased aSAH volume. Among younger patients, higher aSAH volume was associated with DCI (odds ratio [OR] 1.04; 95% CI 1.02-1.06; P < .001), clinical vasospasm (OR 1.02; 95% CI 1.01-1.03; P = .02), and 7-day mortality (OR 1.05; 95% CI 1.02-1.07; P < .001). In elderly population, larger aSAH was only associated with 7-day mortality (OR 1.04; 95% CI 1.01-1.07; P = .01).

Conclusion: Older age, bifurcating aneurysms, and higher Hunt and Hess are associated with larger aSAH volumes. In younger patients, greater aSAH volume is linked to an increased risk of DCI, clinical vasospasm, and 7-day mortality. Among older patients, increased aSAH volume is only associated with 7-day mortality.